Carla (daughter, POA) — confirm 24/48h post-DC coverage.
NEMT for SNF transfer OR family pickup if home.
Pre-stage education, meds-to-beds, Sat speech eval slot.
BlueShield MA — neuro slot via Stanford referral desk.
Primary agency cannot start within 48h; search in-network alternatives.
Fri-to-Mon risk: SLP eval must happen before weekend staffing drop.
Diuresis target met, BNP trend, weight stable 24h.
TUG, transfers, stairs. Required for SNF acceptance.
Push portal preference form to Carla.
Submit via CoverMyMeds. TAT 24h.
Daily weights, fluid restriction, when to call.
20-min bedside teach + pen-needle stock.
BlueShield requested mobility details before approving SNF level of care.
Three accepted SNFs; family ranking needed before referral packet goes out.
Avoid the 4 PM pharmacy cliff for CHF discharge meds.
Teach daughter warning signs, anticoag precautions, and fall-prevention plan.
Primary home infusion nurse unavailable; find alternate start-of-care.
Central line teach-back required before BMT discharge.
Medicare SNF packet complete; confirm bed hold and arrival window.
Awaiting facility acceptance; tracking against 7d bed-hold.
Sacubitril/valsartan (Entresto): PA pending 343.9h · MEDICARE_ADVANTAGE expedited SLA 72h, standard 168h (CMS-0057-F (Apr 2024) · MA PA streamlining).
SNF auth not yet initiated — risk of weekend slip.
Awaiting authorization; tracking against 7d bed-hold.
ALC — Awaiting Guardianship; file/track petition (CA conservatorship ~4–6 wks).
No caregiver — home-with-support not viable without arranged care.
SNF auth not yet initiated — risk of weekend slip.
Screen flags guardianship needed; no surrogate decision-maker secured — facility routing held (ALC — Awaiting Guardianship).
Attending has not attested; awaiting rounds.
Attending has not attested; awaiting rounds.
Awaiting authorization; tracking against 7d bed-hold.
Attending has not attested; awaiting rounds.
Awaiting authorization; tracking against 7d bed-hold.
SNF auth not yet initiated — risk of weekend slip.
Awaiting authorization; tracking against 7d bed-hold.
3-midnight qualifying stay not yet met (observation days do not count).
Awaiting authorization; tracking against 7d bed-hold.
Awaiting authorization; tracking against 7d bed-hold.
Awaiting authorization; tracking against 7d bed-hold.
Attending has not attested; awaiting rounds.
LTCH_LTAC auth not yet initiated — risk of weekend slip.
Attending has not attested; awaiting rounds.
Attending has not attested; awaiting rounds.
ALC — Awaiting Guardianship; file/track petition (CA conservatorship ~4–6 wks).
No caregiver — home-with-support not viable without arranged care.
Screen flags guardianship needed; no surrogate decision-maker secured — facility routing held (ALC — Awaiting Guardianship).
Awaiting authorization; tracking against 7d bed-hold.
Awaiting authorization; tracking against 7d bed-hold.
Active behavioral risk (SI/psychosis/withdrawal) — unsafe for home or unlicensed settings.
Reconcile home meds vs. inpatient. Flag duplicates + interactions.
BMT post-induction needs daily infusion 14d.
Court hearing in 11d. Need affidavit pack.
ARU medical director needs endurance and stair tolerance before acceptance.
Humana denied Entresto; prepare exception packet and safe alternative.
Memory care funding path needs Medicaid waiver screen and charity bridge.
Pending morning rounds (~10:30).
PT evaluation pending — SNFs will reject any referral packet without it.
PA pending (PENDING). CMS standard 7d / expedited 72h.
Apixaban (Eliquis): PA submission timestamp missing.
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
Eligibility check not yet completed — run 270 before any auth submission.
Pending morning rounds (~10:30).
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
Pending morning rounds (~10:30).
Pending morning rounds (~10:30).
Preference form not yet sent — caregiver cannot select disposition until delivered.
Pending morning rounds (~10:30).
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
Pharmacist queued for DC-eve reconciliation.
Eligibility check not yet completed — run 270 before any auth submission.
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
Eligibility check not yet completed — run 270 before any auth submission.
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
Eligibility check not yet completed — run 270 before any auth submission.
Pending morning rounds (~10:30).
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
Pharmacist queued for DC-eve reconciliation.
Eligibility check not yet completed — run 270 before any auth submission.
Preference form not yet sent — caregiver cannot select disposition until delivered.
Pending morning rounds (~10:30).
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
Pending morning rounds (~10:30).
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
Pending morning rounds (~10:30).
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
Pending morning rounds (~10:30).
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
Eligibility check not yet completed — run 270 before any auth submission.
Pending morning rounds (~10:30).
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
Pending morning rounds (~10:30).
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
Pharmacist queued for DC-eve reconciliation.
Eligibility check not yet completed — run 270 before any auth submission.
Preference form not yet sent — caregiver cannot select disposition until delivered.
PT evaluation pending — SNFs will reject any referral packet without it.
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
Pending morning rounds (~10:30).
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
Pending morning rounds (~10:30).
PT evaluation pending — SNFs will reject any referral packet without it.
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
Eligibility check not yet completed — run 270 before any auth submission.
Pending morning rounds (~10:30).
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
Pending morning rounds (~10:30).
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
Pending morning rounds (~10:30).
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
PT evaluation pending — SNFs will reject any referral packet without it.
Pharmacist queued for DC-eve reconciliation.
Preference form not yet sent — caregiver cannot select disposition until delivered.
Verify Entresto formulary tier + pharmacy stock at CVS Mission St.
BlueShield denied. P2P slot needed within 24h.
Originally ETA Wed; backup Apria warmed.
Need medical-director review and fallback plan if LTCH declines.
Kaiser specialty pharmacy must confirm same-day courier for discharge meds.
Wound care needs medical respite; backup shelter lacks clinical support.
FHIR pull + CHF summary + auth template for 3 SNFs.
Echo signed 11:31. One-click DC pending.
6th-grade reading level. Awaiting RN review.
Home oxygen vendor needs signed CMN before routing driver.
Query Bayview, Hillcrest, Marin Manor for beds Mon AM. All accept MA HMO.